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Patient Access API

Da Vinci Payer Data Exchange (PDex)

The DaVinci Payer Data Exchange IG (PDex) and the US Core IG (USCDI) define how Clinical Data is provided. The Da Vinci PDex solution started with the goal of providing payer sourced information to providers in the form of FHIR resources consistent with US Core profiles for FHIR Release 4. Da Vinci expanded the scope of PDex to include not only payer-to-provider exchange at the request of the provider, but also payer-to-third-party-application exchange at the request of the member.

Provisioning Clinical Data is defined by the Da Vinci Payer Data Exchange (PDex) and US Core Implementation Guides, while provisioning Plan Coverage and Formularies is defined by the Da Vinci Payer Data Exchange US Drug Formulary Implementation Guide.

The Da Vinci PDex IG covers the exchange of:

  • Claims-based information via clinical FHIR profiles, namely US Core plus payer-specific profiles for Device and MedicationDispense.
  • Clinical information (such as Lab Results, Allergies and Conditions).

This information is exchanged using US Core and Da Vinci Health Record Exchange (HRex) Profiles. This superset of clinical profiles forms the Health Plan Member’s Health History.

The Da Vinci PDex IG covers the exchange of a member’s Health History in the following scenarios:

  • Provider requested Provider Health Plan Exchange using CDS-Hooks and SMART-on-FHIR
  • Member-authorized Health Plan to Health Plan exchange
  • Member-authorized Health Plan to Third-Party Application exchange

Note: The latter two scenarios are provided to meet the requirements identified in the CMS Interoperability Notice for Proposed Rule Making issued on February 11, 2019.

PDex vs. US Core

Unlike the US Core 3.1.0 Implementation Guide, PDex provides guidance for payers about making the following information available via a Patient Access API:

  • Provenance appropriate for payer data exchange with extended US Core Provenance (USCDI/US Core profiles are not sufficient)
  • Dispensed medications (not covered in US Core)
  • Non-implantable medical devices (not covered in US Core)
  • Common Payer Consumer Data Set (CPCDS) to US Core and PDex profiles to satisfy the requirement for exchange of USCDI V1.1 information
  • Clinical data received by payers (such as laboratory results) from multiple sources (e.g., claims, HL7 v2, CDA) to the appropriate FHIR US Core and PDex profile data elements

Claims

Information coming from claims is represented as USCDI v1.1 information. This includes, at a minimum, encounters, providers, organizations, locations, dates of service, diagnoses (conditions), procedures, and observations. This would also include clinical information from sources other than claims that are maintained by the payer, such as:

  • Laboratory results received via HL7 V2 ORU transactions
  • Clinical data from HL7 consolidated CDAs
  • Information derived from HL7 V2 ADT transactions
  • Information received or extracted from immunization registries
  • Information related to medication administration from pharmacy benefit managers in pharmacy networks
  • FHIR resources and any other source of clinical information related to the member

Search Parameters

The following table describes the search parameters for the ExplanationOfBenefit resource that are required by this Implementation Guide.

Parameter Type Example
_id token GET {{baseurl}}/ExplanationOfBenefit?_id=[id]
_lastUpdated date GET {{baseurl}}/ExplanationOfBenefit?_lastUpdated=[_lastUpdated]
identifier token GET {{baseurl}}/ExplanationOfBenefit?identifier=[system]|[code]
patient reference GET {{baseurl}}/ExplanationOfBenefit?patient=[patient]
type token GET {{baseurl}}/ExplanationOfBenefit?type=[system]|[code]
service-date date GET {{baseurl}}/ExplanationOfBenefit?service-date=[service-date]

Mapping Claims and Encounters

Information about mapping claim and encounter data from the Consumer-Directed Payer Data Exchange IG (CARIN for Blue Button®) to fields in the respective clinical (US Core and PDex) profiles are provided on the Mapping Adjudicated Claims and Encounter Information page.

Additional Resources